=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215156930
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARRELL JON SCHOLTE CTRS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7621 CANOGA AVE
-----------------------------------------------------
City | CANOGA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91304-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-598-6973
-----------------------------------------------------
Fax | 818-719-9152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4630 WOODLEY AVE UNIT 104
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-598-6973
-----------------------------------------------------
Fax | 818-719-9152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------